Living Donation with Dr. Gabriel Danovitch

Dr. Samra sits down with Dr. Danovitch. They talk about the importance of slowing the progression of chronic kidney disease by using medications such as SGLT2 i and GLP-1 RA.  

They identify and recognize how hard it is to wait and the uncertainty of getting a transplant 

How dialysis is getting better even though it only provides you about 15-20% of your kidney function and allows patients to feel better. 

There are certain things that can preclude one from getting a transplant. Such as active cancer, infections. 

There are two types of transplants. Deceased donor and living donor. A living donor transplant can have huge advantages such as not ever starting dialysis, and getting a transplant sooner. 

It may be beneficial to be listed at multiple transplant centers. 

The number of years on dialysis is important. 

Living donation is the preferred avenue for kidney transplantation. 

1)low wait time

2)kidneys tend to function better and longer

3)you get the transplant on a fixed day and can better prepare for it

Traditionally, living donation came from close family member, parents, siblings etc. 

Can have friends, neighbors, from your religious place of gathering. 

The health of the donor is very important.  They undergo a very intense evaluation process to ensure that it is safe for them to be a donor. 

Its a beautiful gift to donate a kidney. Dr. Danovitch shares a endearing story of a donor. 

These days you don't you have to be a perfect match. There are ways for us to get around incompatibilites. Organ exchanges or organ chains are one such way. 1/3 of living donors done are done through such exchanges.

Have an open mind towards those who want to donate a kidney to you. 

They ended the conversation with discussing kidney exchanges as a way to get around incompatibilites.

https://www.ovid.com/jnls/transplantjournal/fulltext/10.1097/tp.0000000000004892~gabriel-m-danovitch-md-frcp-hon

https://www.livingdonortoolkit.com/

Please note this is not medical advice. It is meant for entertainment purposes only. 

Transcript

SPEAKER_00 0:02

All right. Welcome everyone to another episode of Totally Transplant. This is your host, Dr. Munbreet Samra. I have a very special guest with us today, Dr. Gabe Danovich. I had the honor of training with Dr. Danovich during my transplant part of my general nephrology fellowship. And Dr. Danovich is the reason that I went into TransWAP. And the reason why I'm sure many of our other colleagues have been inspired to go into this field. So without further ado, Dr. Danovich, can you please introduce yourself to the audience?

SPEAKER_01 0:38

Okay, so I'm my name is Gabriel Danovich. I'm originally British, lived in Israel, but have lived in the United States, New York, and Los Angeles for nearly 50 years. Have the honor and privilege of being a mentor to Memphis, the lovely lady you see here. It was indeed my privilege, and it's been a joy to see what an amazing career she has and is making for herself and for the patients and colleagues that she works with. That's basically what it's all about. I was fortunate that I got into transplantation basically in early 1980s. In the early 1980s, for the first time, the drug that you patients may well have heard about, cyclosporin, was first was first uh approved by the FDA for use in organ transplantation. And that drug basically changed the world. I think its discovery in the late 1970s, probably one of the major discoveries of modern medicine, because without it and the drugs that followed, uh, we wouldn't have transplantation, not just of kidneys, but hearts and livers and lungs and pancreas and all the other organs. I was involved in transplantation about a year before cyclosporine came along, and the results were not good. I would say the chances of success were 50-50, something like that. And many patients did not do well, and the kidneys were lost, and they went back to dialysis, or worse. And remarkably, when cyclosporin first came out, it was a dramatic shift in the outcomes of transplantation, a dramatic shift, um, such that from going, say, from 50-50 to percentages now where we talk about 90%, 95%, even higher percentage of success of kidney transplantation. And so I was fortunate to be part of that. And interestingly enough, in the beginning, because cytosporin is it, and and the drug that followed it, mainly tacharolomus, prograft, that you probably many of you are familiar with, they're very similar drugs. They're complicated. And in the beginning, since I had experience with it, all of a sudden people around me decided that I was the expert. It's a thing in medicine. I often tell colleagues, even people like Mampre, that, and medical students, I tell them that in medicine it's it's a good idea to take one particular thing and kind of know more about it than anybody else. And then all of a sudden, you're the expert. And it makes life more interesting and more important and more valuable to you as a professional to feel there are certain fields that you really are the authority. And so, in the beginning, everyone people were very nervous of these medications, but over the years, people have become much more familiar with them, and we know much better how to use them, and other drugs have come along. And so, kidney transplantation has become very successful. In some respects, we and you, the patients, are the victims of this success because more and more people want transplants, yet the availability of organs for them is limited. And I suspect we'll likely be limited for a long time. And to my mind, even though people say, Oh, we need more transplants, we need more transplants, yes, it's true we need more transplants, we need more kidneys, but to my mind, we need to be better and do a better job at recognizing and preventing chronic kidney disease, because there's so much unrecognized kidney disease in the United States and around the world, that however many transplants we do, it's like an iceberg. You know, all you see is the tip of the iceberg, and underneath that iceberg in this country and around the world, because of diabetes and hypertension and obesity and all other kinds of things, there's a lot of unrecognized kidney disease. Fortunately, and Mampreet is very well aware of this, in the last four or five years, a remarkable new groups of drugs have become available to us that actually may make a big difference in slowing significantly the progression of chronic kidney disease. I'm not going to go into those today. Maybe that's a topic for another time. But I think it's very important if you do have some level of kidney disease, that you make sure that your physicians, your nephrologists, or your doctors are aware of some of the amazing new drugs that have the opportunity of significantly slowing the progression of kidney disease. So that hopefully you won't ever ever need a transplant, or at least you will get many more years out of your own kidneys. That's a separate topic. But I think it's good news for everyone with kidney disease that the last few years has seen, after a long period where really things were fairly static, in the last few years we've seen the introduction of a whole new series of drugs. You've probably heard about them on the news. I'm not going to go into them in detail, but people talk about them a lot. They're called SGL2 and GLP1s. They have all these funny names, but they really are beneficial for diabetes, for kidney disease, for heart disease. And they're really, they're really changing medicine for the benefit of patients with kidney disease. And the benefits of patients with transplants that are not working well. It can also help them too. But for those of you who are waiting for a transplant or think a transplant is coming, first of all, we understand that it's very hard. It's hard to wait, it's hard to have uncertainty, and it's hard to live with anxiety of knowing you've got a disease and you're not quite sure how it's going to play out or what your future is going to be, and your family and your responsibility and your works and your work. It's not easy. And we identify and recognize the stress that it must represent to you for you. But fortunately, there are things that we can do. Different types of dialysis. Dialysis is getting better, but dialysis essentially only provides you with about maybe 15-20% of your kidney function. It puts you, those of you who are aware of the kind of staging, it puts you like from what we used to call stage five to stage four or stage three, but it doesn't bring your kidney function to close to normal. A successful transplant can bring your kidney function to close to normal. And therefore, life feels much closer to normal because you can go about your life without worrying about machines. Most of the time, people with transplants feel a lot better. They feel more normal, they have more energy, and they often think better or feel better and less fatigued. So if you can, you really the great advantage would be if you have quality kidney disease to get a transplant. Now, not everyone with quantity kidney disease can get a transplant, because sometimes there are illnesses that interfere, a prior history of cancer, uh uh difficult infections. I'm not going to go into that now, but basically everyone who's seeking a transplant needs to go through an evaluation process to determine if indeed they're a candidate. If indeed, fortunately, you are a candidate, the question is when am I going to get this transplant? When am I going to get this transplant? And essentially, there are two types of transplants from transplants from dead people and transplants from living people. It is a huge advantage, a huge advantage if you can get a transplant from a living donor. Huge advantage. One, because you don't have to wait that long. And two, sometimes if you're fortunate and you're not on dialysis yet, a living donor transplant can avoid dialysis altogether, which is the ideal. So ideally, one would get a living donor transplant. If you don't have, I'll come back to that in a minute. If you don't have a living donor transplant, then you need to go on a waiting list and you wait. And around the country, the waiting time varies. I can tell you that where I live in Southern California and most of California, the waiting time is really long. It's awful. It's measured in seven, eight, nine, ten years. Around the country, the average is probably four or five years. There are places for all kinds of geographic reasons and population reasons why the waiting time is less. I'm not going to go into that now, but your transplant program or your transplant of experts could tell you where those are. You are allowed, according to the rules, to put your name on transplant lists, more than one transplant list. So if you have the ability financially, personally, family-wise, to be on a list where the waiting time is less, that is an advantage for you. And then that's something for you to talk about with your doctors, where your insurance companies, all the logistics that I'm not not going to, I'm not going to go into now. People on dialysis, be aware of the fact that the time that you are waiting or your time on the waiting list is determined by basically how long you're on dialysis, so that if you get sick while you're on dialysis, that time doesn't go away. And your doctors will explain that to you. Ideally, try to get on the transplant list when your kidney disease is far advanced, but you're not on dialysis yet. But I do want to talk more about living donation. So living donation is clearly the preferred avenue for kidney transplantation. As I said, for a variety of reasons. One, you don't have to wait that long. Two, the kidneys tend, I can't guarantee this, tend to function better and tend to function longer. The other thing is that you get the transplant on a fixed day. That is, a day is chosen for the transplant, whatever it is, August the second. So you know when it's going to be, and you can be prepared for it. You're prepared for it physically, medically, and emotionally for the transplant. Whereas for a transplant from a dead person, you never quite know when it's going to happen. You never quite know when it's going to happen. So you have that anxiety. With a living donor transplant, you know when it's going to be. Bearing in mind, the fact, although everyone is afraid of operations, the operation itself, fortunately, has been done so frequently and is done by people who really know what they're doing. So the operation itself is not regarded as a highly dangerous or highly risky operation. Yeah, of course, every operation has some risks, but in good hands, you're very likely to do very, very, very well. Your team will explain to you all the different side effects, et cetera, that you need to go through. But the great majority of people do very, very well. Now, where does the living donor come from? Traditionally, over the years, when I first got into this, donation came from close family members. So they were either brothers, siblings, or parents, or children. Over the years, we learned that you don't really have to be closely matched to someone to become a donor, and that people who are actually unrelated to the donor, like friends, neighbors, people from your church or your mosque or your synagogue or whatever you go could potentially be donors for you. What matters more is not so much the matching, but what matters more is the is the health of the donor and the quality of the kidney. Understand that donors go through a really intense evaluation process to make sure it's safe for them and that they go through the process with no significant impact on the rest of their lives. There are some impacts. Most of the time they're minor. It's not free of risk, but when done properly, the risk is really very, very small. So donation actually, people who donate kidneys actually have a very good feeling about themselves. This is one of the most beautiful things that a human being can do for another person is to donate a kidney. Sometimes I tell patients, you know, all of us, all of us, on a birthday or Christmas or whatever it is, we like to get gifts. But giving someone a gift that is just right is often more gratifying than getting that gift. I know you've given someone a gift that that's just what they wanted is often more gratifying than actually getting that gift. So being a donor, I'm going to tell you a story actually. It's a short happened to me. I was on a flight from uh on an airline from, I don't know, from the East Coast over the West Coast, and I was working on some on some slides for a lecture, and then one of the flight attendants kind of looked at the slides and said, Oh, are you a transplant doctor? I said, Yes. She said, Oh, I donated a kidney to another flight attendant. I said, Whoa, that's wonderful. And everyone, I said out loud, she donated a kidney to a flight attendant, and everyone started clapping, and we hugged her, and she had a halo on her head. And I say that that's the halo that donors can walk around with a halo. You can see the pride on her face that she had done something beautiful. So there is actually a gain from being a donor, a gain in a sense of self-worth, of having done something absolutely marvelous. So when kidney donation is done right and done ethically and appropriately, the donor not only gives, but also gains in that sense of self-worth that they have. And the outcomes are really for donors very, very good. They need follow-up and et cetera, et cetera. We're going to that. Now, because you don't have to be closely related to be a donor, someone will say, Oh, I'll donate a kidney to you if I'm a match. Well, the truth is these days you don't have to be a match. You don't have to be a match, because we can get around any incompatibilities. There are varieties of ways we can do that. Sometimes we can do it with medicines. Moreover, these days, we're less likely doing it with medicines, but we do it with what we call swapping, organ exchange. That is, let's say you want to donate a kidney to your brother or sister, and for some reason you're the wrong, that's not the right word, you're a different blood type. And you can't do it directly. So, what can happen is you can donate a kidney to someone else, and then that other donor can give to the person that you love that you want to have. And these days, these so-called kidney exchanges and kidney chains have become really common, really common. And I say this off the top of my head, about a third of all living donor transplants these days are done through kidney exchange. Other example could be: let's say you have a husband and wife, and the husband and wife are a couple, they live alone, and they say, Well, I can't donate to my husband or husband, because who's going to take care of him or her? Well, what you can do is the donation can take, you can go donate to someone else at a different time. The other person can look after them while they're recovering, and then when they're recovered, someone else can give to your person. So we can get around these things. It's a matter of putting our heads together, trying to be innovative and interesting, and we can get around all these things as long as we have what I call an open mind. All living donations need to have an open mind. Let me give you an example of an open mind that I come across over and over again. And this is the issue of parents accepting kidneys from their children. Now, biologically, you expect that a parent would donate to a child. I mean, that's kind of the child, your child needs a kidney, or your brother and sister needs a kidney. It's kind of a natural, kind of biological, kind of normal you donate. Generally speaking, a parent doesn't expect a child to be the one. And many parents, understandably, I'm a parent, understandably, feel protective about their children or their spouse. No, I don't want my wife to go through this. I don't want my husband to go through this. No, no, I can't let my child be a donor. I hear that a lot. But those children aren't children anymore. They may be 25, 30, 35 years old, or 40 years old, or 40, whatever, whatever it is. And they're grown adults. And grown adults make grown adult decisions. I have an example, for instance, I see this happen a lot. A parent may need a transplant and they have a child who's a grown, healthy child who wants to donate to them. And they say, No, no, I can't accept from my son and my daughter. I would say, but if your son and your daughter were donating a kidney to another child, would you have a problem with that? No, no, no, that's fine. Oh, but you don't want to take it for yourself. But you'll be okay if they give it to your other brother and sister, but not for yourself. Well, I would say that by preventing them from giving a kidney to you, you are preventing them from showing their love for you. You're preventing them from showing their love and caring for you by being, oh, I'm the tough. I see this, oh, I'm the tough one. No, I can't accept. Well, have an open mind because donors are adults, the process is going to protect their health. You wouldn't have a problem if they donated to someone else. But here you are. It's you now. And I thought myself myself. I try to put myself in this position. So I have kids. Fortunately, I don't have kidney disease. My kids are grown. If I had kidney disease and one of my kids said to me, Dad, I want to give you a kidney. Let me tell you what I would do. I would be reluctant originally. I would lose some sleep. I would probably shed a tear or so. But I would let them do it. Because I know they love me. I love them. I believe they love me. And they would be showing, I would make sure that they get taken care of properly, of course, that they're evaluated carefully and their health, all of that. That's a gibbon. But I would have that open mind. And the other example I give to patients is this. They say, I can't accept a kidney from my son or my daughter. I said then I would say to them, Well, that that's interesting. If your dad, 25, 30 years ago, if your dad had kidney disease or your mom, would you give a kin to them? Of course I would. Of course I would. Well, of course I would. And what would you do if they would say no? I would say, no, dad, I want to do it. Well, this is happening the other way around now. Exactly. This happened the other way around now. You know, so all I'm saying is I'm not making it easy. I'm not trying to make it easy. And you might want to shed a tear or lose a night's sleep, but have an open mind. Have an open mind because I'll give you another example, for instance, in a married couple, when one person has kidney disease, and this is true by the way, not just for kidney disease, it's also true for any chronic illness. If your partner has a chronic illness, it's hard for the partner. There's a whole topic of partner fatigue. It's hard for the partner if the person you love is sick. So by donating to them, to some extent, you're making your own life better because you have a healthy partner. So that's another time example. You want to have a healthy partner because then both of you can enjoy life more. So that's basically how I want people to have an open mind to living donation. To not be afraid, if you're a member of a community, a church community, a religious community, a political community, whatever community you're part of, to share with your friends and colleagues. And someone may come forward as a potential donor, bearing in mind the fact their interests will be protected. So have an open mind because living donation is clearly the best option for you if you have chronic. Disease. How are we doing for time? How do we do it for time, Grand Prix?

SPEAKER_00 22:03

Time is great. I think what you outlined is so important, Dr. Danovich, to have that open mind in accepting that beautiful gift that is of living donation and leave it up to us to make sure to do that rigorous assessment of your loved one, of the donor, because we will not move forward with it unless it's safe.

SPEAKER_01 22:24

By the way, I want to make an important point. The evaluation of the donor is totally separate than the evaluation of the recyclant. So that the donor has their own doctor, their own team, and it's separate from that of the recipient. So that there's no confusion, there's no kind of conflict as to, oh, maybe I'll do this for that and this for that. No, because they have their own separate team whose job it is solely to look after the interests of the donor.

SPEAKER_00 22:55

Yes.

SPEAKER_01 22:56

And the bottom line is education, education, education. Learn as much as you can. There are plenty of wonderful resources out there: the National Kidney Foundation, the American Society of Transplantation, the American Society of Transplant Surgeons, there are other living donor groups. So I would encourage you to look at these resources. There are a lot of excellent resources out there. And Mampreet or your own kidney doctors will make sure that those resources, because there's so much nonsense on the internet these days, to make sure those resources are those resources that you can, that you can rely on and for a comfortable.

SPEAKER_00 23:33

Absolutely. We'll include those in the show notes, absolutely. And Dr. Danovich, I mean, I I think you outlined just this concept of living donation and accepting this beautiful beautiful gift. Where do you think the future of transplantation is going?

SPEAKER_01 23:49

So that's a tough question. So first of all, I do want to say that I still believe that prevention is better than cure. And that it's going to be a long time till we can. I mean, the future of transplantation may well be what's called xenotransplantation. Xeno is a Greek word which basically means stranger, foreign. And xenotransplantation means getting a kidney from an animal. Typically it would be a pig, a pig kidney that's being made in a way that can become one of these days. There are some early, early experience with xenotransplantation. I think it's going to happen. It's going to happen. I've always said it's around the corner. It's always will, and I always said it always will be around the corner. Well, now at least we can see a little bit around the corner. It may actually be around the corner. It's not going to be, it's going to be a long time before you're going to be able to go to the fridge, take out a kidney, a pig kidney that's being modified in some way and plug it in. You know, it's going to be a long time. Maybe one day that will happen. I don't know that I'll be around to see that happen, but maybe one day that will happen. In the meantime, in the meantime, we're still waiting for transplants. We're still waiting for living donation or deceased donation. I still believe that the answer, if there is an answer to the big waiting list, is going to be prevention, prevention, prevention, recognition, prevention, prevention. I don't think we're ever going to quite be able to keep up with the demand. Because the demand, as I said, I think in the beginning of when we talk, is so great and so underrecognized and so underrecognized. So for the moment, for the foreseeable future, we're dealing with deceased and living donor transplantation. And keep your eyes open for new developments, new medicines, new ways of going about things. But I do really believe that probably the greatest advance in transplantation in the last 10 or 15 years has been these living donor exchanges, where we can arrange for people to be transplanted, even though it appears as if they are a quotation marks, incompatible. So different kinds of incompatibility, but we can get around those incompatibilities in innovative ways and having an open mind.

SPEAKER_00 26:17

Wonderful. You know, for patients that are listening, they they may not know that Dr. Danovich wrote the book on kidney transplant, The Handbook of Transplantation. That's a wonderful book to read. That is what I read through my fellowship. I still have a signed copy from fellowship to now that I will every once in a while show.

SPEAKER_01 26:38

You read it before you go to bed, Mampre. You meet it that's like it make you go to sleep. It's better than a sleeping pill.

SPEAKER_00 26:45

But the seventh edition is out now. And I think I just wanted to share that. That's amazing to leave such a legacy and to contribute so much. I want to thank you.

SPEAKER_01 26:56

It's my privilege. And my privilege, I can't tell you how enormously proud I am of you. And what you're doing now is spreading the good word and spreading care for people for whom getting that care may not be that easy. So bless you, dear. Thank you. Thank you.

SPEAKER_00 27:13

And thank you for your time today.